Executive Response to the C&AG's Report on Governance Arrangements for Health and Social Care Follow-up (R.143/2021)

Recommendations

Action

Target date

Responsible Officer

R1  Document  a  comprehensive  and publicly  available  Health  and  Social Care  Integrated  Governance Accountabilities (IGA) Framework. This structural document should include:

• terms of reference of committees and groups

• relationships between the committees and groups

• memberships, workplans  and frequency of meetings

• arrangements both within HCS, within Government and within the whole Island health and social care system; and

Many of the principal strands of HCS governance have already been established (including TOR):

• Level 1: HCS Board & Board Committees

• Level 2: Care Group Performance Reviews

• Level 3: Care Group Management / Governance meetings

• Level 4: Speciality / Service level

• Level 5: Department / Individual

Key actions:

• Develop  an  Accountability  Framework  which specifies  how  the  performance  management systems are structured and tracked, to ensure

April 2022

HCS Secretary/ Director General

• the  Jersey  Care  Model  and  Our Hospital  project  governance arrangements

delivery of the corporate objectives at every level of the organisation.

Review the effectiveness of the subcommittee / management group structure (including TOR / work plan).

Develop the Integrated Governance Framework document for HCS

Further  develop the  framework to  include the Whole Island system / JCM / our Hospital

June 2022

June 2022

September 2022

R2  Review the terms of reference for and the membership of the HCS Board. This review should consider:

• the  membership  within  Government and external to Government

• the responsibilities of the HCS Board in respect of all Government health and social care services (within and external to HCS); and

• the role and responsibilities of the HCS Board for the whole health and social care system on the Island.

A review of the Terms of Reference will consider all these points & this process will start at th meeting 8 November 2021. (Attached are Draf TOR in Appendix A)

Revisions  Q4 e 2021  Final  Draft t Q1 2022

HCS Board Secretary / Director General

R3 Review the way in which the HCS Board operates in order to:

• ensure that a more effective balance is struck  between  verbal  and  written reports

• ensure  that  the  minutes  record accurately who is present' as a HCS Board  member  and  who  is  in attendance'

• require the  HCS  risk  register to  be reported to the HCS Board on at least an annual basis; and

Ensuring  a  more  effective  balance  is  struck between verbal & written reports is too simplistic. The TOR / annual work plan will be developed to ensure the Board prioritises the issues on which they  spend  their  time  (including  setting  the organisation's  strategy  and  overseeing  its performance, governance and compliance with its legal obligations).  This is to be recorded on the  agenda  /  planner.  Items  delivered  will  be mapped to HCS objectives with a description of purpose of presentation. Following this, need to determine what information is most relevant & the way in which the Board needs to receive the

Q1 2022

HCS Board Secretary / Director General

• ensure that the  Director General  of HCS and other Senior Executives are held  to  account  in  an  open  and transparent way.

COMPLETE

(see website April 2021)

information.  Where  decisions  /  actions  are required, written information will be required. The  minutes  have  always  recorded  this.  For clarity,  the  word  Board'  has  been  inserted  – Board Members Present.

Health and Community Services Department Board

(gov.je)

The HCS Risk Register is discussed within the Quality & Risk Assurance Committee report. Health and Community Services Department Board

2022

(gov.je)

However, to make it clearer the specific inclusion of the risk register will form part of 2022 HCS Board Work Plan.

The HCS Board is a meeting in public' (although this was disrupted during the pandemic) where the Chair holds the DG / Executive Directors to account.  The  BoardPack  / minutes  are  made publicly available through the HCS website.

 Q1 2022

Health and Community Services Department Board

Q4 2021

(gov.je)

Develop a handbook for HCS Board members to ensure they can undertake their responsibilities effectively and appropriately.

R4 Prioritise the finalisation of the Board Assurance  Framework  to  support  the work of the HCS Board. This document should  be  publicly  available  and  be updated and publicised on at least a six monthly basis

The  development  of  a  Board  Assurance Framework has been discussed in detail with the GOJ Risk & Audit Team. The development of a BAF will be considered in conjunction with the GOJ Risk management Strategy, however, this is a long-term project. Once a detailed timeframe

Q4 2025

HCS Board Secretary / Director General

and work programme for the development of the Framework is in place, this will be shared with the CAG.

A Risk Manager has been appointed & will be commencing mid-Nov 2021. This role will ensure the  development  &  embedding  of  risk management  processes  within  HCS  &  the maintenance of a risk register which fully reflects risk exposure.

Q4 2022

R5 Publish an Annual Quality Account for all health and social care services provided by Government. The Annual Quality  Account  should  include,  as  a minimum, information on:

• a  review  of  performance  over  the previous  year  across  the  domains  of patient/service  user  safety,  clinical effectiveness and patient experience

• identification of and progress made in identified areas of improvement

• the outcomes of clinical audit

• the outcomes and recommendations from  internally  commissioned  external clinical services reviews undertaken in the year

• action taken and proposed in respect of  clinical  audit  and  other  reviews  of services

• core  quality  indicators,  including benchmarking of performance over time and against other health and social care systems where possible and appropriate

• the volume and themes from feedback including feedback from patients/service

The introduction of an organisation wide Quality Account enabling staff to reflect on their hard work and celebrate their achievements and successes has been identified as a key deliverable within the ratified Quality and Safety Strategy 2021-2023. Work on this will commence early 2022 with the aim of being able to provide an annual quality account for 2022.

This will include:

• A review of performance over the previous year across the domain of patient/service user safety, clinical effectiveness and patient experience

• The outcomes and progress made meeting the recommendations of national and local clinical audits

• Learning from Serious Incidents and Moderate harm incidents looking at themes across HCS

• The outcome of internally commissioned external clinical service reviews

• Core quality indicators in line with the NHS 15 quality indicators and NHS Outcomes framework

• The volume, feedback and themes from complaints, whistleblowing and PALS service

Q4 2023

Quality & Safety Team / Director Quality & Safety

users, system partners, complaints and whistleblowing; and

• key  themes  from  staff  surveys  with actions  planned  in  response  to  staff feedback

Themes from staff surveys such as BeHeard and the action planned in response to staff feedback

R6  Consider  appointment  of independent members to the assurance committees  to  ensure  that  there  is appropriate  independent  challenge  of and assurance over performance.

Review the constitution & renumeration of other GOJ Boards  (for  example  Law  Officers  Department)  to explore how this could be developed within HCS.

Q1 2022

HCS Board Secretary

R7 Ensure that robust arrangements are in place to update the data supporting the Jersey Performance Framework on a more regular basis.

The indicators in the Jersey Performance Framework are now being aligned with those in the HCS Quality & Performance report as the two reports will be publishing in the same time period (quarter end). The JPF has a tight quarterly timetable for submission and sign off which has now been shared with reporting teams across Government (from Q3 2021) enabling planning of workload and submission.

Data extraction issues from the core health system (TrakCare) have been recurring over recent months and indeed worsening. HCS Informatics is working with M&D to find a solution that enables robust data extraction that does not impact the live system. The Outpatient API has been implemented in October

2021 and the plan is to complete the rest by the end of 2021. Once the data are available to the team, the analysis and report production has been developed in Alteryx – software which allows repeatability and rapid turnaround of reports.

Q3 2021

Head of Informatics

R8 Document a long term strategy for health  and  wellbeing  to  be  delivered across Government, health and social care  services  and  key  partners.

People & Corporate Services  are developing a GOJ Wellbeing Strategy. Health will present their strategy to compliment this.

Q3 2022

Head of Organisation Development (COO) / Associated

Progress against the long term strategy should be reported publicly.

Chief for allied Health Professionals and Wellbeing

R9 Complete the review of a PALS and prioritise the establishment of a PALS or equivalent service.

A review of the PALs service has been completed. A Task  &  finish  group  is  being  set  up  to  review  and establish the PALS function going forward.  Pilot of PALS desk in Gwyneth Huelin from October – December 2021. This will provide users of our service any guidance, support,  advice  or  information  should  they  have concerns, suggestions or queries about their care at point of contact. Service users will be signposted to local services,  support  groups  and  complaints  process,  if necessary.

Q4 2022

Chief Nurse

R10  Review  the  level  of  business support provided to the Care Groups.

A HR business partner and a financial business partner will be allocated to each care group

Q2 2022

Associate Director of People (HCS) / Head of Finance Business Partnering (HCS)

R11  Document  a  more  formal programme  of  planned  benchmarking and peer to peer' learning.

Document  to  be  created  on  programme  of  planned benchmarking projects.

Document to be created on a peer to peer' learning

programme.

Q4 2022

Director of Improvement & Innovation / Medical Director

R12 Document and implement a formal action  plan  to  rollout  JNAAS  to  all community providers.

JNAAS was temporarily suspended during the Covid Pandemic. At that time, JNAAS had been implemented across all inpatient HCS areas and Jersey Hospice Care. JNAAS has now recommenced, and all HCS inpatient areas will have been assessed by December 2021. At the initial discussions with some community providers, there were no immediate plans to introduce a community JNAAS  frameworks,  due  to  competing  priorities. However, this will be further reviewed in line with the commissioning processes.

Q4 2022

Associate chief Nurse (Professional Practice)

We are already creating frameworks for our own HCS Mental Healthcare Teams and have templates that can be modified for other community teams/providers. The templates  can  be  individualised  to  commissioned organisations, without losing the standardised evidence- based benchmarks we use.

R13 As part of the implementation of the Jersey  Care  Model,  explore  ways  of sharing  information  and  learning  from complaints across all parts of the health and social care system, including from primary care providers.

To  include  "sharing  information  and  learning  from complaints" as a standing agenda item in the JCM Health and Care Partnership Group. Health and Social services report feedback into Datix. This is then reported to the executive as part of the Quality and performance care group reporting.

To produce a summary report against this agenda item by end of 2022.

Note:  The  JCM  Health  and  Care  Partnership  Group provides a seat for all health and care providers on island and  therefore  would  be  a  good  place  to  share  and explore ways of improving the sharing of learning from complaints.

Q4 2022

Director of Improvement & Innovation

R14 Redefine the expected behaviours supporting the Team Jersey Values into a language specific to the delivery of health and social care services for HCS staff.

The GoJ Team Jersey team to co-produce with HCS staff and HCS Team  Jersey Leads the re-wording of the expected  behaviours  supporting  the  Team  Jersey Values to make them relevant to clinical and non-clinical support staff in a health and care environment.

Updated documentation produced and published.

Q4 2022

Director of Improvement & Innovation / Programme Director Team Jersey/Head of Organisational Development

R15 Implement a more comprehensive quality and safety programme across all health and social care services.

The Quality and Safety Strategy 2021-2023 has been approved within HCS and will be rolled out in Q1 2022. The Strategy describes:

how we organise ourselves

Q1 2022

Quality & Safety team / Director Quality & Safety

• how we will imbed an open learning culture cross- cutting  throughout  all  our  structures  how  we  will implement constant improvement; and

• how  we  will  measure  and  share  this  success  in delivering a new Jersey Standard for Quality and Safety within health and social care for all Islanders.

R16 Extend further the scope and nature of  routine  public  reporting  of  the performance of all elements of health and social care, including through the Government of Jersey website, taking into  account  performance  reporting  in other jurisdictions.

Reporting  is  currently  restricted  due  to  technical limitations and staffing capacity.

The new EPR system (implementation by end of 2022) will enable better and easier reporting. In the meantime, we will

review  options  for  public  reporting  including taking  into  account  performance  reporting  in other jurisdictions

Q3 2022

Head of Informatics / Director of Improvement & Innovation

R17 Improve the arrangements for the management of risks by:

• documenting the risk appetite for the key risks identified on the risk register

• ensuring that risk mitigation actions are aimed  at  managing  risks  within  the identified risk appetite

• clarifying the interaction between the HCS  approach  to  risk  and  the Government ERM approach

• improving the audit trail through the assurance  committees  and  the  HCS Board  as  to  how  risks  have  been managed on and off the risk register; and

• ensuring the HCS Board reviews the top health and social care system risks on a systematic basis at least twice a year.

A Risk Manager has been appointed & will start mid- November to further develop & embed risk management process within HCS. This will incorporate actions to meet the recommendation in full.

A Risk Management Committee has been established (see attached TOR)

The  risk  appetite  document  is  being  developed  for presentation  at  the  Risk  Management  Committee. Following agreement here, this document will need to be presented to the Senior Leadership for approval & the Quality & Risk Assurance Committee for assurance.

The inclusion of the Risk Register at the HCS Board will feature on the annual work plan for 2022

Q4 2021

Q4 2021

Q1 2022

Appointed Risk Manager

R18 Ensure that the quality and safety programme to be implemented includes a comprehensive strand of work aimed at developing the capacity and capability of  all  those  involved  in  delivering governance  across  health  and  social care.

Governance standards will be developed alongside the Quality and Safety strategy.

Quality and Safety resources across HCS should be pulled into a central team in order to have the capacity and capability to deliver the governance across HCS.

Q3 2022

Quality & Safety team / Director Quality & Safety

1. Name of governance body

Health and Community Services (HCS) Risk Management Committee

2. Constitution (who approved the establishing of the board and when)

The Risk Management Committee is a standing subcommittee of the Quality and Risk Assurance Committee.

3. Accountability (who the board/committee are accountable to)

The Committee is accountable to the Quality and Risk Assurance Committee for its performance

and effectiveness in accordance with these terms of reference.

4. Authority (what has been delegated to this board / committee)

The Committee is authorised to investigate any activity within its terms of reference. It is

authorised to seek any information it requires from any employee and all employees are directed

to co-operate with any request by the Committee.

5. Duration of governance body (how long this governance body is permitted)

This committee is a permanent subcommittee of the Quality and Risk Assurance

Committee.

6. Purpose

The purpose of the HCS Risk Management Committee is to:

Ensure  a  consistent  approach  to  risk  management  within  HCS  that  aligns  to  the

Government of Jersey (GOJ) Risk Management Strategy.

Ensure that risk management practices are operating effectively across all areas within

HCS.

Provide a consolidated and considered view of HCS departmental risks to inform the

corporate risk register.

Support the objectives of the Enterprise Risk Management (ERM) Strategy and the

implementation of this to further increase the maturity of risk management within HCS.

Provide assurance and advice to the Quality & Risk Assurance Committee in respect of

risks facing HCS & plans to mitigate these risks.

Review and update the HCS risk management process in line with the GOJ Risk

Management Strategy.

7. Duties and responsibilities

To  ensure  the  identification,  evaluation  and  monitoring  of  key  risks  that  threaten

achievement of HCS's strategic objectives and that a register of these risks is maintained.

Support the development of consistent risk management practices and processes across

HCS, communicating and embedding this throughout.

Encourage and promote an effective risk management culture across HCS.

Ensure that risk is identified and managed in accordance with HCS's risk appetite and

tolerances, and where this is exceeded, action taken to reduce the risk.

Horizon scan for new and emerging risks that could impact on any part of HCS.

Ensure that the HCS risk register is up to date and all risks have an action plan with

regular reports of progress against these.

Review new risks and associated controls and actions entered onto the HCS Risk Register and confirm their acceptance onto the register as live risks.

The  development  and  identification  of  key  risk  indicators  to  further  support  the

assessment of risk.

Review departmental training needs in terms of risk management. Identifying training requirements and receive and review evaluations / outcomes following provision of training.

Invite services / departments and corporate functions to attend the committee on a

rotational basis to present a risk report on their risk register and key actions taken.

Consider and approve the remit of the risk management function and ensure that it has

adequate resources, processes and appropriately access to information to enable it to

perform its function effectively.

Provide assurance to the Quality and Risk Assurance Committee that risk management

practices and processes are in place and effective. Where gaps have been identified,

provide assurance that action plans are in place and being monitored to address this.

Reviewing all HCS and Ambulance Service risks >15 and all Children, Young People,

Education and Skills (CYPES) >11 included in the risk register.

Consider the assessment of these risks, identifying and challenging risks that warrant

escalation to the Senior Leadership Team.

Challenge risk handlers / managers on actions taken to mitigate these risks & update on

progress against these.

Undertake deep dive exercise of each risk on an annual basis (minimum) to understand the effectiveness of active risk management around these, to support the risk on its "path to green".

8. Membership

Members:

The following posts are the permanent membership of the Committee,

• Director of Quality and Safety (Chair)

• Chief Nurse or Delegate (Vice Chair)

• Group Managing Director or Delegate

• Group Medical Director or Delegate

• Associate Director of People HCS or Delegate

• Head of Finance Business Partnering HCS

• Head of Informatics HCS

• Risk Manager HCS

• Head of Estates

• Head of Non-Clinical Support Services

• Care Group SLT Representative

• Chief Clinical Information Officer

• Head of Allied Healthcare Professionals

• Chief Pharmacist

• Head of Therapies

In attendance:

The following posts shall be invited to attend routinely meetings of the Committee in full or in part but shall not be a member:

• Board Secretary

The Committee can request the attendance of any other person if an agenda item requires it.

9. Chairmanship (details of chair and deputy chair)

The Committee shall be Chaired by the Director of Quality and Safety, in the interim period Chief Nurse.

If the chair is absent or has a conflict of interest which precludes his or her attendance for all or part of a meeting, the Committee shall be chaired by the Vice Chair.

10. Quorum (the minimum number of members that must be present for it to be proceed)

For any meeting of the Committee to proceed, six members must be present. The following combination of members must be present:

• One Executive Director

• Risk Manager

• Four other members

Non-quorate meetings may go ahead unless the Chair decides not to proceed. Any decision made by the non-quorate meeting must however be formally reviewed and ratified at the subsequent quorate meeting.

11. Decision-making (how decisions will be made i.e. voting member and how non-agreement will

be resolved)

Wherever  possible,  members  of  the  Committee  will  seek  to  make  decisions  and recommendations based on consensus.

12. Subgroups (details of any sub-groups that will report into this board/committee)

N/A

13. Responsibility of members and attendees (what is expected of members and attendees)

Members and attendees have a responsibility to:

• attend at least 80% of meetings.

• read all papers before the meeting.

• disseminate the minutes, additional information, and good practice as appropriate amongst the senior management team within areas of responsibility.

• identify agenda items, for consideration by the Chair, to the Board Secretary at least 10 working days before the meeting.

• prepare and submit papers for a meeting, using the approved report template, at least 8 working days before the meeting.

• if unable to attend, send their apologies to the Board Secretary at least 24 hours prior to the meeting and, if appropriate, seek the approval to send a deputy to attend on their behalf. Deputies must be appropriately senior and empowered to act on behalf of the committee member.

• when matters are discussed in confidence at the meeting, to maintain such confidences.

• declare any conflicts of interest / potential conflicts of interest as set out below.

• conduct themselves in a manner consistent with Our Collective Values and Behaviours', challenging colleagues and partners that do not.

14. Conflicts of Interest (expectation of members / attendees to declare conflicts)

Committee members should declare conflicts of interest in relation to agenda items as they arise.

15. Secretariat (who will provide secretariat and expectations)

The Risk Manager shall provide administrative support and advice to the Chairperson and membership. The duties shall include but not limited to:

• Preparation of the draft agenda for agreement with the Chairperson

• Organisation of meeting arrangements, facilities, and attendance

• Collation and distribution of meeting papers

• Taking the minutes of meetings and keeping a record of matters arising and issues to be carried forward

• Maintaining the Risk Management Committee work programme

• Maintain a schedule of meeting dates and a rolling programme of proposed agenda items.

• Standing agenda items will be:

• Welcome and apologies
• Conflicts of interest
• Minutes of the previous meeting
• Matters arising
• Matters referred from other groups / Committees
• Action tracker

• Ensuring the ToR review is an agenda item prior to the date the ToR document is due for review.

16.  Meetings

Meetings of the Committee shall be formal, minuted and compliant with relevant statutory and good practice guidance including Government of Jersey, Our Collective Values and Behaviours and Dignity and Respect.

The Committee will meet monthly.

The Chair of the Committee may cancel, postpone, or convene additional meetings as necessary for the Committee to fulfil its purpose and discharge its duties.

17.  Frequency of meetings (how often the meetings will take place and when)

The Committee will meet monthly.

18. Papers (when papers should be submitted and circulated prior to meeting)

All items for future agendas should be notified to the Risk Manager at least 10 working days before the date of the meeting at which it is proposed that the item is considered.

Agenda and Papers will be circulated 5 working days before the meeting.

Tabling of papers will be allowed by exception only and with the agreement of the Chair; late arrival or tabling of important agenda items severely constrains the quality of debate and likelihood of decisions being reached.

19.  Minutes (expectation when minutes will be circulated following meeting)

Minutes of the meeting are formally recorded. Draft minutes of the meeting shall be prepared by the Risk Manager and Chair after every meeting and circulated to members within five working days.

Minutes of the Committee's meeting shall be recorded formally and ratified by the Committee at its next meeting.

20. Reporting (open or closed meeting)

Discussions should be regarded as closed' sessions for the purposes of Freedom of Information (FOI) regulations.

The Risk Manager shall prepare a report of each meeting for submission to the Quality and Risk Assurance Committee at its next meeting.

Issues of concern and/or urgency will be reported to the Senior Leadership Team in between formal meetings by other means and/or as part of other meeting agendas as necessary and agreed with the Director General.

The Committee will produce monthly reports for the Quality & Risk Assurance Committee.

21. Terms of Reference Review (ToR approval and review)

These Terms of Reference were approved by <insert> on DATE.

These Terms of Reference shall be reviewed biannually or more frequently if necessary.

The next scheduled review of the Terms of Reference will be undertaken by the Committee in December 2021 in anticipation of approval by the Quality and Risk Assurance Committee at its meeting in July 2021.

Any changes to these terms of reference must be approved by the Quality and Risk Assurance Committee.